RU2741700C1 - Method for performing oncoplastic resection of a mammary gland with central and medial tumor location - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. Breast tissues are excised with subsequent replacement of the volume with native tissues on the feeding pedicle. Mammary gland is accessed from an arc-shaped incision passing along the inner border of the areola in sector for 1 to 7 hours. Breast tissue is removed in amount of 1 cm from the tumor boundary. Arcuate skin incision is made along the lateral edge of the mammary gland on the border with the axillary region, continuing into the epigastric region to the midline of the abdomen. Then in the upper part of the incision subcutaneous fat is dissected for 6 cm, axillary lymph node dissection is performed, an angiosomal thoraco-epigastric skin-subcutaneous flap directed to the blade area is formed. Produced flap is de-epidermised, a retromammary tunnel is created between a cavity of a mammary gland wound and a skin incision on the border with an axilla through which the de-epidermised thoraco-epigastric flap is moved into the mammary wound cavity. Lower edge of the epigastric portion of the skin incision is mobilized to the umbilicus.

EFFECT: method enables minimizing the risk of cosmetic formation (incisions are made in natural folds and the boundary line of the areola transition into the skin of the anterior surface of the breast, the breast is formed one time and subject to cicatrical deformation) and functional (congestion in the lymphatic system is minimized due to features of angiosomal thoraco-epigastric skin-subcutaneous flap formation) postoperative complications.

1 cl, 2 ex, 1 tbl, 9 dwg

Description

The technical field to which the invention relates

The invention relates to medicine, namely to surgery. State of the art

Breast cancer (BC) ranks first in the structure of oncological morbidity in the Russian Federation among the female population, and its constant upward trend is noted. At the same time, more than 60% of patients reveal relatively early (I-II stages) forms of breast cancer. BC diagnosed at early stages is characterized by a favorable prognosis and high rates of relapse-free and overall survival: in stage I, more than 95% of patients survive 5 years. The choice of the scope of the operation depends on the oncological situation: the stage of the disease, the possibility of conducting radiation therapy, the patient's age and wishes. The importance of preserving the breast for a woman can hardly be overestimated. When the tumor is localized in the medial parts of the breast, the operation of a radical resection of the breast can be performed from two skin incisions in the breast and in the axillary region.

In the world, the most commonly used options for organ-preserving surgery are lumpectomy (in the Russian version, sectoral resection of the breast with axillary lymphadenectomy) and quadranthectomy (radical resection). Organ-preserving surgeries without a plastic component are not always aesthetically sufficient for patients; the use of plastic components of the surgery makes it possible to level these problems. Currently, many oncoplastic resection techniques are radical in the oncological aspect and improve aesthetic results. When planning an oncoplastic operation, the planning of skin incisions and oncological excisions of the parenchyma is carried out using the principles of mammoplasty and mastopexy, remodeling of the gland after an oncological excision, centralization of the nipple-areolar complex (NAP), achieving contralateral symmetry.

The oncological component does not differ from radical resection in the classical sense: urgent histological examination of the wound edges, intraoperative marking of the tumor bed with radiopaque clips for subsequent radiation therapy, the volume of lymphadenectomy depending on the stage of breast cancer. In fact, oncoplastic resections are the movement, rotation or transposition of large areas of the breast to fill the defect, transposition of the SAH to centralize it after resection, which improves the aesthetic result. A common disadvantage of the proposed methods is a significant reduction in the size of the "diseased" breast, the need for a second stage of surgery to correct the size and shape of the "healthy" breast.

Known (analogue) "Method of primary breast plastics after its subtotal radical resection" (RF patent for invention No. 2177265 from 20.07.2001). The method consists in "restoring the volume and shape of an organ with a displaced flap and endoprosthesis, for which a muscle bed is created, characterized in that a teardrop-shaped fatty skin flap cut from the lateral surface of the chest wall, corresponding in size to a skin defect of the mammary gland, is used in one block with a part the broadest muscle of the back, the excess of which corresponds to the width of the flap, for which the skin with fiber is separated to the required level from the broadest muscle outward from the lateral incision, which is the outer border of the cut flap, to the side of the back, where the muscle is crossed, the flap is taken up and the wound on the chest wall is sutured layer by layer, then the excess of the broadest muscle is tucked under the flap and its lower edge is sewn with the lateral edge of the pectoralis minor, and provisional sutures are applied between its upper edge and the lateral edge of the pectoralis major muscle, an endoprosthesis is inserted into the prepared muscle bed and the sutures are tied, then the displaced flap is fixed to the edge pits of a skin defect in the breast ".

This method has the following disadvantages:

- the occurrence of an extensive cosmetic defect on the lower surface of the breast;

- the muscle corset of the chest is broken;

- the occurrence of congestion is possible in case of violation of the lymphatic outflow from the axillary region and the anterolateral surface of the chest;

- the development of postoperative asymmetry of the mammary glands is possible due to the development of cicatricial changes in the displaced muscle flap and the presence of an artificial implant.

Known (prototype) "Method of simultaneous reconstruction of the mammary gland in organ-preserving surgical treatment of cancer of the I and II stages of internal quadrants" (RF patent for invention No. 2585427 dated 05/27/2016). The method includes "preoperative marking, resection of the mammary gland and axillary - subclavian - subscapular lymphadenectomy, according to the marking, a periareolar circular incision, a semilunar skin incision is performed, the upper border of which is 18-19 cm from the level of the clavicle along the midclavicular line 1-2 cm to the landmark a new location of the nipple, further from the medial and lateral edges of the formed semicircle, vertical incisions are made down to the middle of the lower slope, from where at an angle of 60 ° to the submammary fold, and an incision along the submammary fold, then de-epidermisation of the marked zone is performed and subcutaneously access to the inner quadrant of the mammary gland - the area of tumor localization, the sector with the tumor is removed together with the fascia of the pectoralis major muscle, regional lymphadenectomy is performed from a separate incision in the axillary region, in the de-epidermis zone, the lower glandular leg is formed to a depth of the fascia of the pectoralis major muscle, the leg is separated from the fascia d about the periareolar zone and unfold it, moving it to the zone of the remote sector of the inner quadrant of the mammary gland, where it is fixed with separate interrupted sutures with an atraumatic thread to the nearest sections of the glandular tissue, the areola is moved to the level of the upper incision, where it is fixed, the skin and subcutaneous flaps of the lower quadrants are sutured in layers, performing simultaneous mastopexy, after which the wounds are sutured layer by layer, leaving vacuum drainage. "

However, this method has the following disadvantages:

- a significant decrease in the size of the operated breast,

- long duration of surgery and anesthesia,

- an increase in the risk of complications due to the implementation of a complex technically complex procedure,

- in some cases, a large area of scars,

- the features of the angiosomal structure of the surface of the human body are not taken into account,

- the need for a second stage of surgery to correct the size and shape of the contralateral breast.

Thus, it is necessary to develop a new method for performing oncoplastic resection of the mammary gland in the central and medial localization of the tumor. In the claimed method, the listed disadvantages are eliminated.

Disclosure of invention

The objective of the invention is to improve the quality of medical care for women in need of surgical resection of breast tumors with central and medial localization.

The technical result of the method is to ensure minimization of the risk of the formation of cosmetic (incisions are made in natural folds and the borderline of the transition of the areola into the skin of the anterior surface of the mammary gland, the mammary gland is formed at a time and is subject to cicatricial deformation) and functional (stagnation in the lymphatic system is minimized due to the features the formation of angiosomal thoraco-epigastric skin-subcutaneous flap) complications in the postoperative period.

Implementation of the invention

The claimed technical result can be achieved as follows:

- After antiseptic treatment of the operating field, according to the hospital's methodology, access to the mammary gland is performed from an arcuate incision passing along the inner border of the areola in the sector from 1 to 7 hours (Fig. 1).

- Carry out mobilization of the nipple-areola complex, remove the posterior-nipple zone and breast tissue in a volume of at least 1 cm from the tumor border (Fig. 2).

- Produce an arcuate skin incision along the lateral edge of the mammary gland at the border with the axillary region, which continues into the epigastric region to the midline of the abdomen (Fig. 3).

- In the upper part of this incision, the subcutaneous tissue is dissected for 6 cm, axillary lymph node dissection is performed. An angiosomal thoraco-epigastric skin-subcutaneous flap is formed, the base facing the scapular region (Fig. 4),

- Spend de-epidermisation of the thoracoepigastric flap (Fig. 5).

- Create a retromammary tunnel between the cavity of the breast wound and the skin incision at the border with the axillary region (Fig. 6).

- The de-epidermal thoraco-epigastric flap is moved through the retromammary tunnel into the cavity of the breast wound, where it is placed replacing the removed breast tissue (Fig. 7).

- Produce mobilization of the lower edge of the epigastric part of the skin incision not less than to the navel (Fig. 8).

- Thoraco-epigastric wound is sutured with a two-row suture (Fig. 9).

The novelty of the proposed method lies in the fact that:

- For the first time during the operation, the volume of the breast tissue is corrected to the initial one at the same time, as a result of which there is no need for a second operation to correct the size and shape of the "healthy" breast.

- For the first time, a thoraco-epigastric flap is used, which has a good blood supply from the scapular vessels in accordance with the theory of angiosomes.

Distinctive features of the method:

- access to the mammary gland is carried out from an arcuate incision passing along the inner border of the areola in the sector from 1 to 7 hours,

- breast tissue is removed in a volume of at least 1 cm from the border of the tumor,

- an arcuate skin incision is made along the lateral edge of the mammary gland at the border with the axillary region, continuing into the epigastral region to the midline of the abdomen, then in the upper part of the incision, the subcutaneous tissue is dissected for 6 cm,

- axillary lymph node dissection is performed, an angiosomal thoraco-epigastric cutaneous-subcutaneous flap is formed, with the base facing the scapular region, the resulting flap is de-epidermal,

- between the cavity of the breast wound and the skin incision at the border with the axillary region, a retromammary tunnel is created, through which the de-epidermal thoraco-epigastric flap is moved into the cavity of the breast wound,

- produce mobilization of the lower edge of the epigastric part of the skin incision not less than to the navel ..

Brief Description of Drawings

FIG. 1 shows a cut of the skin along the edge of the areola in the inner quadrants of the right breast.

FIG. 2 shows the mobilization of the nipple-areola complex, the removal of the posterior nipple zone and breast tissue in a volume of at least 1 cm from the tumor border.

FIG. 3 shows the execution of an arcuate skin incision along the lateral edge of the mammary gland at the border with the axillary region, which continues into the epigastric region to the midline of the abdomen.

FIG. 4 depicts the formation of a thoraco-epigastric skin-subcutaneous flap, the base facing the scapular region.

FIG. 5 shows de-epidermisation of the thoracoepigastric flap.

FIG. 6 shows the creation of a retromammary tunnel between the cavity of the breast wound and the skin incision at the border with the axillary region.

FIG. 7 shows the movement through the retromammary tunnel of the de-epi-dermisized thoraco-epigastric flap into the cavity of the breast wound.

FIG. 8 shows the mobilization of the lower edge of the epigastric part of the skin incision not less than to the navel.

FIG. 9 shows the suturing of a thoraco-epigastric wound with a two-row suture.

The proposed method is illustrated by the following examples.

Thus, under equal initial conditions, the application of the proposed technique made it possible to improve the patient's quality of life.

Claims (1)

A method for performing oncoplastic resection of the mammary gland with central and medial localization of the tumor, which consists in excising the breast tissue with subsequent volume replacement with its own tissues on the feeding pedicle, characterized in that access to the mammary gland is carried out from an arcuate incision passing along the inner border of the areola in the sector from 1 to 7 o'clock, breast tissue is removed in a volume of at least 1 cm from the tumor border, an arcuate skin incision is made along the lateral edge of the mammary gland on the border with the axillary region, continuing into the epigastric region to the midline of the abdomen, then the subcutaneous incision is cut in the upper part of the incision cellulose over 6 cm, axillary lymphadenectomy is performed, an angiosomal thoraco-epigastric cutaneous-subcutaneous flap is formed, facing the base to the scapular region, the resulting flap is de-epidermal, a retromammary is created between the cavity of the breast wound and the skin incision at the border with the axillary region tunnel, through which the de-epidermal thoraco-epigastric flap is moved into the cavity of the breast wound, the lower edge of the epigastric part of the skin incision is mobilized at least to the navel.

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